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ENVIRONMENT AND BEHAVIOR / January 2001Taylor et al. / COPING WITH ADD

COPING WITH ADD

The Surprising Connection

to Green Play Settings

ANDREA FABER TAYLORis a doctoral candidate at the University of Illinois,

Urbana-Champaign. Herresearch focuses on thedesign of developmentally support-

ive outdoor environments for children.

FRANCES E. KUO is an assistant professor and codirector of the Human-Environ-ment Research Laboratory at the University of Illinois, Urbana-Champaign. Her re-

search focuses on attention, defensible space, and novice-friendly information.

WILLIAM C. SULLIVAN is an associate professor and codirector of the Human-

Environment Research Laboratory at the University of Illinois, Urbana-Champaign.

His research focuses on the psychological and social benefits of urban nature and on

citizen participation in environmental decision making.

ABSTRACT: Attention Restoration Theory suggests that contact with nature sup-

ports attentional functioning, and a number of studies have found contact with every-

day nature to be related to attention in adults. Is contact with everyday nature also

related to the attentional functioning of children? This question was addressed

through a study focusing on children with Attention Deficit Disorder (ADD). This

study examined the relationship between childrens nature exposure through leisure

activities and their attentional functioning using both within- and between-subjects

comparisons. Parents were surveyed regarding their childs attentional functioningafter activities in several settings. Results indicate that children function better than

usual after activities in green settings and that the greener a childs play area, the

less severe his or her attention deficit symptoms. Thus, contact with nature may sup-

port attentional functioning in a population of children who desperately need

attentional support.

Over 2 million childrenin the United States alone are struggling to cope

with a chronic attentional deficit, Attention Deficit Disorder (ADD) (Barkley,

54

AUTHORS NOTE: This research was conducted in partial fulfillment of therequire-

ments for a doctoral degree in Natural Resources and Environmental Sciences at the

ENVIRONMENT AND BEHAVIOR, Vol. 33 No. 1, January 2001 54-77

2001 Sage Publications, Inc.


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1995).1ADDreduces childrens attentional capacity and in doing so, has det-

rimental effects on many aspects of life (e.g., school, interpersonal relation-

ships, personal growth). Unfortunately, of the available treatments, some

have costly side effects, and the remaining have limited effectiveness. Sur-

prisingly, the physical environment has not been examined as a potential

source of support for children with ADD. Attention Restoration Theory

(Kaplan, 1995) proposes that naturemaysupport attentional functioning,and

a growing body of evidence indicates that, in adults with regular attentional

capacity, nature is supportive of attentional functioning. Could natural envi-

ronments support attentional functioning in children with attention deficits?

The study presented here examined the effects of childrens afterschool and

weekend activity settings on their attention deficit symptoms.In this section, we describe ADD and its treatment, review the previous

work on nature and attention, and present the central questions motivating

this study.

ATTENTION DEFICIT DISORDER

Attention Deficit Disorders are surprisingly common and have far reach-

ing consequences. ADD occurs in about 3% to 7% of school-age children(Barkley, 1997; Bender, 1997; Hinshaw, 1994). Moreover, there is substan-

tial evidence thatADDinchildhood can disrupt cognitiveand socialdevelop-

ment in several pivotal areas. First, children with ADD tend to have poor

academic performance (for reviews, see Barkley, 1997; Bender, 1997;

Hinshaw, 1994). Second, they are at increased risk for problems in the social

arena as well. For example, they tend to have poor peer relationships and are

often rejected by their peers (Alessandri, 1992; for reviews, see Bender,

1997; Berk, 1994; Hinshaw, 1994). They also tend tohavepoor relations withtheir parents and have a higher rate of family conflict (Barkley,

Anastopoulos, Guevremont, & Fletcher, 1992). In addition, children with

ADD tend to display more aggressive and antisocial behavior (for reviews,

Taylor et al. / COPING WITH ADD 55

University of Illinois, Urbana-Champaign. This research was supported by a grant

fromthe National Urban and Community ForestryAdvisory Council, and the Cooper-

ative State Research, Education, and Extension Service, U.S. Department of Agricul-

ture under Project No. ILLU-65-0387l. We thank all the parents who participated inthis research project, especially Patrick Sullivan. We also thank Dr. Lisa Monda-

Amaya, Dr. Annette Lansford, and Dr. William Stewart for their helpful suggestions.

Correspondence concerning this article should be addressed to Andrea Faber Taylor,

Human Environment Research Laboratory, University of Illinois, 1103 S. Dorner Dr.,

Urbana, IL 61801, or [email protected].


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see Barkley, 1997; Hinshaw, 1994). Perhaps it is not surprising, then, that

childrenwithADD are often alsoatgreater risk for low self-esteem,anxiety, and

depression (for reviews, see Barkley, 1997; Bender, 1997; Hinshaw, 1994).

ADD is essentially defined as a developmental lag in the specific area of

attentional control. Thus, diagnosis involves evaluating a childs attentional

control relative to their same-age peers (American Psychiatric Association,

1994). Specifically, theDiagnostic and Statistical Manual of Mental Disor-

ders (DSM-IV)defines ADD as a persistent pattern of inattention that is

more frequent and severe than is typically observed in individuals at a compa-

rable level of development (AmericanPsychiatric Association, 1994, p. 78).

Barkley (1998) suggests that children with ADD can be expected to display

attentional control at a level 30% behind their same-age non-ADD peers; forexample, a 10-year-oldADD child generallydisplays behaviors more typical

of a 7-year-old child.

Current evidence suggests that this lag in attentional development is due

to biological factors (Barkley, 1995; Shue & Douglas, 1992). For example,

physiological recordings obtained through magnetic resonance imaging

show physical differences in the brain morphology of children with ADD.

Specifically, the right frontal lobe, which plays a key role indirectedattention

(Foster, Eskes, & Stuss, 1994), was found tobe smaller inchildrenwithADD(Hynd, Semrud-Clikeman, Lorys, Novey, & Eliopulos, 1990) than in chil-

dren with age-appropriate attentional control. Thus, although folk theory

holds that the immaturity of behaviors in ADD children is the product of

social factors such as poor parenting, the evidence suggests that ADD is a

biologically based disorder and not the product of the social or physical envi-

ronment (Barkley, 1998; National Instituteof Mental Health[NIMH], 1994).

HOW IS ADD TREATED?

Current treatments for ADD are limited in effectiveness and have many

shortcomings(for reviews, seeFiore,Becker, & Nero, 1993; Hinshaw, 1994).

Stimulant medications, such as Ritalin, Dexedrine, and Cylert, are the pri-

mary treatment for ADD (Hinshaw, 1994; NIMH, 1994; Swanson et al.,

1993). In 9 out of 10 children, these medications help sustain attention and

provide temporary gains in academic productivity (NIMH, 1994), but unfor-

tunately, they fail to improve childrens long-term social and academic out-

comes (for review, see Hinshaw, 1994). In addition, these medications have

serious side effects. They often suppress appetite anddisrupt sleep (Hinshaw,

1994; NIMH, 1994), and in some children, they induce extreme depression

and unusually flattened affect (Douglas, 1972).

56 ENVIRONMENT AND BEHAVIOR / January 2001


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Behavioral therapies are a second form of treatment for ADD. These

include direct contingency management, in which children earn or lose

points for specific behaviors, and cognitive behavioral procedures, in which

children learn how to self-monitor attention and impulsive behavior (for

review, see Fiore et al., 1993; Hinshaw, 1994). Unfortunately, these therapies

are typically not sufficient tobring children intonormal rangesof functioning

(Fiore et al., 1993; Hinshaw, 1994).

Given the difficulties associated with medication and behavior ther-

apy-based treatments, there is a clear need to explore alternative means of

treating ADD. Could contact with nature support the attentional functioning

of children who haveADD? Both theory and evidence regarding the relation-

ship between contact with nature and attentional functioning suggest itmight.

NATURE AND ATTENTION

Attention Restoration Theory (Kaplan, 1995) proposes that natural envi-

ronments can assist attentional functioning. To understand how this might be

so, let us review Jamess (1892/1962) theory of attention, and then Kaplans

(1995) application of that theory to Attention Restoration Theory.James proposed that humans have two types of attention: voluntary and

involuntary. Voluntary attention, or what Kaplan (1995) calls directed atten-

tion, is the kind of attention we use when we deliberately pay attention. This

form of attention is employed in attending to tasks (e.g., problem solving) or

situations (e.g., driving in heavy traffic) that require sustained attention and

that are not inherently easy to attend to. After prolonged and intense use,

directed attention becomes fatigued (Glosser & Goodglass, 1990; Kaplan,

1995). By contrast, involuntary attention is easy and does not require effort(James, 1892/1962). James suggested that certain elements in the environ-

ment draw on our involuntary attention: strange things, moving things, wild

animals, bright things, pretty things, words, blows, blood, etc. etc. etc.

(James, 1892/1962, p. 231). Reliance on involuntary attention can be useful

for the rest and recovery of fatigued directed attention. Kaplan (1995) pro-

poses that stimuli andenvironments that draw primarilyon involuntary atten-

tion give directed attention a chance to rest. Attention Restoration Theory

suggests that natural environments assist in recovery from directed attention

fatigue inpart because theydrawon involuntary attention rather thandirected

attention (Kaplan, 1995).

A number of studies in adult populations support Attention Restoration

Theory. Several studies have shown that nature draws on involuntary atten-

tion (e.g., Kaplan, 1973, 1983; Kaplan & Talbot, 1983; Ulrich, 1981). In



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addition, a number of other studies have shown that exposure to natural envi-

ronments can be effective in restoring directed attention from fatigue (Canin,

1991; Cimprich, 1990; Hartig, Mang, & Evans, 1991; Kuo, in press; Lohr,

Pearson-Mims, & Goodwin, 1996; Miles, Sullivan, & Kuo, 1998; Ovitt, 1996;

Tennessen & Cimprich, 1995). In one study, exposure to natural environ-

ments through leisure activities was shown to be related to attentional func-

tioning in adults. A study of AIDS caregivers found that nature activities and

quiet activities were associated with robust attentional functioning, whereas

activities such as TV watching, shopping, and watching or playing organized

sports were associated with poorer attentional functioning (Canin, 1991).

NATURE AND ATTENTION IN CHILDREN

Could contact with nature support attention in children? Theoretical and

empirical work in landscape architecture and environmental psychology has

addressed numerous possible other benefits of nature for children, including

providing privacy, mental stimulation, and sensory stimulation and support-

ing important developmental activities such as play, creative forms of play,

and exploratory and divergent thinking (Heseltine, 1987; Jansson, 1984;

Kirkby, 1989; Miller, 1972; Moore, 1986, 1989; Nabhan & Trimble, 1994;Senda, 1992; Striniste & Moore, 1989; Taylor, Wiley, Kuo, & Sullivan, 1998;

Trancik & Evans, 1995). Only one article has raised the question of natures

potential impacts on childrens attention (Trancik & Evans, 1995). Trancik

and Evans (1995) suggest that the design of day care settings should include

spaces supporting restoration, such as natural areas, because preschool

children may be susceptible to mental fatigue as they adapt to a new pre-

schoolenvironment. However, this idea hasnotbeen empirically examined.

There are reasons to think that Attention Restoration Theory extends tochildren. Like adults, children maybecome attentionally fatigued. For exam-

ple, childrens schoolwork requires extended periods of deliberate, effortful

attention. And like adults, children often must carry out these tasks in a con-

text filled with powerful distractions that constantly demand attention,

making it extremely difficult to concentrate on the task at hand. In addition,

because childrens attention is not fully developed (Mackworth, 1976; Shaffer,

1985), they may be fighting off distractions with less attentional control than

adults. Thus, children may need attentionally supportive environments

where they can go to restore. It seems plausible that natural environments

might support attention in children, including children with ADD.



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This study examined whether contact with nature assists attentional func-

tioning in children with ADD. Two hypotheses were formulated and tested:

one regarding the immediate aftereffects of contact with nature, and the other

regarding the general effects ofnature on the severityof a childs ADD symp-

toms. Specifically, we proposed that

Hypothesis 1: Attentiondeficit symptoms will be more manageable after activities

in green settings than after activities in other settings.

Hypothesis 2: The greener a childs everyday environment, the more manageable

their attention deficit symptoms will be in general.

To address these hypotheses, we conducted a surveyof parents of childrenwithADDs. For eachchild, we collected information about the aftereffectsof

leisure activities conducted in different settings, the amount of nature in their

everyday environment, and the severityof their symptoms ingeneral. In addi-

tion, six possible alternative explanations for a nature-attention relationship

were examined.

METHOD

The questionnaire and procedures for this study were developed through a

multifaceted qualitative data collection effort. The methodology was guided

by interviews with children with ADD, their parents, and a variety of profes-

sionals with expertise in ADD (pediatricians, a professor of special educa-

tion, and a fifth-grade teacher). The methodology was also guided by

classroom observations of four ADD children (10-11 years old).

The questionnaire was pretested with four different families, one familyata time. As parents completed each section of the questionnaire, the following

concerns were addressed: (a) whether the activities included in the survey

adequately covered the range of activities 7- to 12-year-olds engage in, (b)

whether parents understood the concept of post-activity attentional function-

ing, (c) whether the rating scales were appropriate, and (d) whether the nature

measures were easily interpretable and usable. After each pretest, revisions

were made to the questionnaire before further pretesting.

It isworth noting thataneffortwas made todevelopa questionnaire for theADD children themselves; however, pretesting indicated that the children

were not able to reliably report on any aftereffects of their activities on their

attention deficit symptoms.



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QUESTIONNAIRE

The final version of the questionnaire was printed as a small booklet that

took about 30 to 40 minutes to complete. On the cover, the following narra-tive introduced participants to the idea that childrens activities might have

aftereffects on their attention.

Think about how you feel after a difficult week. You may find it more difficult

than usual to pay attention. On the other hand, after a good vacation, you may

find that its relatively easy to focus your attention.

We suspect that the same may be true forchildren. There are many different

ways children can spend their time outside of school. For children with atten-

tion deficits, its possible that some activities leave children functioning better

than usual, while other activities leave children in worse shape.

In other words, perhaps during the hour or so afteryour child does a certain

activity, you find that their ADD/ADHD symptoms are worse than usual. Or

vice versa;perhaps afterdoinganother activity, you find thatyour child is func-

tioning better than usual.

To make the conceptattentional functioningmore concrete, four specific

attention deficit symptoms were listed:

Cant stay focused on unappealing tasks (homework or chores)

Cant complete tasks

Cant listen and follow directions

Easily distracted

These symptoms are modified selections from the diagnostic criteria for

Attention Deficit/Hyperactivity Disorder (pp. 83-84 of DSM-IV; APA,

1994). Because Attention Restoration Theory suggests a relationshipbetween nature and attentional functioning, but not necessarily between

nature and hyperactivity-impulsivity, only symptoms ofinattentionwere

selected. In addition, because parents rarely observe their children in the

classroom, only symptoms readily apparent in a home setting were

presented.

In the first section of the questionnaire, participants were asked to nomi-

nate up to two afterschool and weekend activities that they felt left their

child functioning especially well and up to two activities that they felt lefttheir child functioning especially poorly. Parents completed the sentence,

After ____ my childs ADD symptoms are much less noticeable than usual.

My child is in good shape. Parents were asked to nominate up to two best

activities. Parents then did the same for worst activities: After ____ my



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childs ADD symptoms are muchmorenoticeable than usual. My child is in

bad shape. For both items, parents had the option of markingnone, if they

had not noticed any activities that were particularly helpful or harmful for

their childs attention. About 66% of parents were able to nominate at least

one activity that was best for their child; 68% were able to nominate at least

one that was worst. Parents nominations were later coded in terms of their

likely settings by an individual blind to the best and worst labels. Each of the

activities was classified as either Green (likely to take place in a relatively

natural setting), Not Green (unlikely to take place in a relatively natural set-

ting), or Ambiguous (ambiguous with respect to physical setting). For exam-

ple, camping trip, fishing, and soccer were coded as Green, whereas video

games, TV, and homework were coded as Not Green. Activities such as play-ing outside and rollerblading were coded as Ambiguous.

In the secondsection, participants were presented witha list of afterschool

and weekend activities and asked to rate each activity in terms of any afteref-

fects of that activity on their childs attention deficit symptoms. These

postactivity attentional functioning ratings, or PAAF ratings, were made on a

5-point Likert-type scale from 1 = much worse to5= much better,withamid-

pointof3= same asusual; dont know was also an option. Twenty-five activi-

ties were presented in three lists: 11 activities conducted indoors, 6 activitiesconducted in built outdoor spaces (defined as mostly human-made areas

parking lots, downtown areas, or just a neighborhood space that doesnt have

much greenery), and 8 activities conducted in green outdoor spaces (defined

as mostly natural areasa park, a farm, or just a green backyard or neigh-

borhood space). Each activity was rated for two social contexts: after the

activity was conducted alone, or with one person, and after the activity was

conducted with two or more people.

In the final section of the questionnaire, parents answered a series of gen-eralquestions about their child, their household, and the childs everyday sur-

roundings. Parents answered the question, In general, how severe would you

say your childs ADD or ADHD symptoms are (when not on medication)?

using a 5-point Likert-type scale, from 1 = very mildt o 5 = very severe. They

reported their childs age, sex, grade in school, diagnoses other than ADD/

ADHD, number of adult caregivers, and the household income. In addition,

parents assessed the greenness of their childs everyday surroundings.

To assist parents in assessing the level of nature in their childs everyday

surroundings, parents were first presented with a set of six photo pairs of pos-

sible play settings ranging fromplaces indoors where it feels very much

indoors(two photos of windowless rooms) toplaces where there might be

wild things: flowers, trees, animals, etc. (two photos of relatively untamed

landscapes). The photo pairs were independently rated by 21 horticulture



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students for greenness or naturalness on a scale of 1 = low to 10 = high), with

an interrater reliability of .994. To avoid collecting information about play

spaces used during other seasons (e.g., winter), parents were asked to select

one photo pair description as representative of where their child played dur-

ing the previous week. Parents were then asked whether their childs activi-

ties in the previous weekwere representativeof their normal routine (yes/no).

In addition to assessing the level of nature in their childs typical play set-

tings, parents were asked toassess the overall greenness of their familys resi-

dence, the amount of tree cover in their yard, and the amount of grass in their

yard. Overall greenness around the home was rated on a 5-point Likert-type

scale (1 = not at all green, 5 = very green). To assess tree cover, parents were

shown four photos depicting yards with different levels of tree cover andasked toselectone thatbest represented the amount of treecover in their front

yard and one that best represented the amount of tree cover in their back yard.

The amount of grass was measured through the same procedure.

PARTICIPANTS AND PROCEDURE

Participation was limited to parents or legal guardians of children 7 to 12

years old who had been formally diagnosed with ADD or ADHD (i.e., diag-nosed by a physician, psychologist, or psychiatrist).

Participants were recruited through flyers distributed to pediatricians

offices, medical clinics, schools, and parent support groups such as Children

andAdultswith AttentionDeficit/ Hyperactivity Disorder (CHADD). Partic-

ipants were also recruited through advertisements placed in major newspa-

pers. Newspaper advertisements were restricted to the midwestern United

States to ensure roughly comparable climate and vegetation across the sam-

ple. The flyers and advertisements invited parents to participate in amail-back or Internet-based survey about the effects of ADD/ADHD chil-

drens afterschool andweekend activities on their symptoms. Two incentives

were offered: a list of recommendations based on the studys findings and a

choice of a pizzeria gift certificate or a childrens book about ADD.

Questionnaire data were collected, as suggested by a pediatrician and spe-

cial education professor, when the attentional demands of school would make

potential effects of nature on attention most salient to parents. Data were

collected from mid-September, after childrens school routines were well

established, through the end of October, before inclement weather might sig-

nificantly limit outdoor play. Paper copies of the questionnaire were mailed

to parents who volunteered by phone or by e-mail, and an electronic version

of the questionnaire was also made available on the Internet. The Dillman

(1978) follow-up methodology was employed to encourage participants to



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return the mail-back questionnaire within the time frame of the study. By the

deadline, 77 paper copies of the questionnaire were returned, or 58% of those

mailed. An additional 19 questionnaireswere completed on the Internet, for a

total of 96 completed questionnaires.

Given the use of convenience sampling, it is important to note that this

samplewas similar toother samples of childrenwith ADDs.The ratio of boys

to girls with attention deficits in the general population is estimated to be 3:1

(Barkley, 1990; Bender, 1997) or even 4:1 (American Psychiatric Associa-

tion, 1994); the ratio of boys to girls in this sample was 3:1. Overall, this sam-

ple had more children with ADHD (61%) than ADD (39%). The ratio of

ADD to ADHD in the general population is estimated at 1:1.7 for boys and

1:2.2 for girls (Szatmari, Offord, & Boyle, 1989); the ratio of ADD to ADHDin this sample was 1:1.6 for boys and 1:1.5 for girls. The percentage of ADD

or ADHD boys having at least one comorbid disorder in the general popula-

tion is 44%, whereas 29% of girls have at least one comorbid disorder

(Szatmari et al., 1989); in our sample, 52% of boys had one comorbid disor-

der, and 36% of girls had one comorbid disorder. The mean age of children in

this sample was 9.4 years, with a standard deviation of 1.5 years. About 63%

of the parents reported their household income to be $50,000 or greater.

After the questionnaire data from the complete sample were analyzed, asubset of questionnaire participants was invited to a focus group dinner to

discuss the findings. Eight questionnaire participants who had indicated

interest in a follow-up interview attended. Focus group participants first

briefly reacquainted themselves with the questionnaire and were asked to

discuss any parts of the questionnaire they had found difficult to understand

or complete. They were then asked if they had any guesses about the central

hypothesisof the study, orwhat the study was after. Someof the major find-

ings were then presented, and participants were asked to describe any experi-ences they had had related toeachof these findings, either inkeeping with the

findings or in contrast to the findings. Finally, participants were asked to

describe their observations regarding different activities, different activity

settings, and their aftereffects on their childrens symptoms

RESULTS

Does contact with nature assist attentional functioning in children with

ADD? First, we present tests of the central hypotheses, along with relevant

quotes and anecdotes from interviews with parents. Then, we present tests of

several alternative explanations for the central findings.



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TESTING OF CENTRAL HYPOTHESES

Each of the two central hypotheses was tested in multiple ways. Tests of

the first hypothesis involved within subjects comparisons; tests of the second

hypothesis involved between subjects comparisons.

Hypothesis 1. The first hypothesis was that attention deficit symptoms

will be more manageable after activities in green settings than after activities

in other settings. This hypothesis was first tested by examining the activities

nominated by parents as particularly helpful (best) or harmful (worst) for

their childrens attention deficit symptoms: 113 best activities and 106 worstactivities were nominated. If green settings are more attentionally support-

ive, then activities typically conducted in green settings should be

overrepresented among the act ivi t ies nominated as best and

underrepresented among theactivities nominatedas worst. Indeed, as Table 1

shows, of the 20 Green activities (activities judged by an independent coder

as likely to take place in a relatively natural setting), 17 were nominated as

best, and 3 were nominated as worst (85% vs. 15%). Furthermore, Not Green

activities were overrepresented among the activities nominated as worst(57%; 43% best). A chi-square confirmed that the likelihood that an activity

would be nominated as best or worst significantly differed for different set-

tings, 2(2) = 12.74,p< .01. This finding raises the possibility that partici-

pants nominated Green activities as best because theyhad guessed the central

hypothesis of the study. However, during the focus group, questionnaire par-

ticipants said they had not guessed that the study was about the relationship

between nature and attention.

The first hypothesis was then tested by examining parents ratings of theirchildrens attention deficit symptoms after participating in various activities

in one of three settings. The mean PAAF rating for all activities was 3.22

(between 3 = same as usual and4= better than usual) with a standard devia-

tion of .48. Mean PAAF ratings for specific activities ranged from 2.14, for

homework with others indoors, to 3.80, for riding bike alone in green set-


TABLE 1

Activities Nominated as Best and Worst for

Attention Deficit Disorder Symptoms, Classified by Likely Setting

Likely Setting Best Worst

Green (e.g., fishing, soccer) 85% (17) 15% (3)

Ambiguous (rollerblading, playing outside) 56% (43) 44% (34)

Not Green (video games, TV) 43% (53) 57% (69)

NOTE: Numbers in parentheses arens for each group.


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tings. If nature is supportive of ADD childrens attentional functioning,

activities conducted in green outdoor settings should receive higher PAAF

ratings, on average, than activities conducted in indoor settings or built out-

door settings. In fact, a repeated measures ANOVA indicates that PAAF rat-ings do differ by setting,F(2, 82) = 15.51,p< .0001 (see Figure 1). Green

activities received a significantly higher PAAF rating on average than indoor

activities, Fishers PLSDd= .30,p< .0001, (M= 3.53 versus 3.22, respec-

tively) and a significantly higher rating than built outdoor activities, Fishers

PLSDd= .28,p< .0001, (M= 3.53 versus 3.24, respectively).

In the comparison of PAAF ratings for indoor versus green outdoor set-

tings reported above, homework was included as one of the indoor activities

because it constitutes an important afterschool and weekend indoor activity.However, whereas the other activities rated in the survey are truly leisure

activities, homework is not a leisure activity, and is particularly attentionally

demanding. Thus, it seems unfair to compare indoor activities to outdoor

activities with homework included as an indoor activity. Hence, we com-

pared PAAF ratings for indoor versus green outdoor activities, excluding

homework from the analysis. Even with homework excluded, the pattern

held, with green outdoor activities still receiving significantly greater PAAF

scores than indoor activities, Fishers PLSDd= .25,p= .0001.

The aftereffects of activities on childrens attention deficit symptoms

were further explored in the focus group. Participants were asked if they had

had any experiences, either positive or negative, related to any aftereffects of

green settings on their childs attention. One parent said she had recently

begun taking her son to the local park for 30 minutes each morning before


Figure 1: Mean Postactivity Attentional Functioning Ratings for Indoor, Built

Outdoor, and Green Outdoor Activities


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school because the weather was nice, and they had some time to kill. She

then said,

Come to think of it, I have noticed his attitude toward going to school has been

better, and his school work has been better this past week. I think its because

spending time at the park is pleasurable, peaceful, quiet, calming.

Another parent suggested that hisson, although usuallystruggling against his

attention deficit symptoms, can hit golf balls with me for 2 hours at a time,

and he fishes for hours at a time alone. This father reported that, after these

activities, his sons attention deficit symptoms are minimal, and hes very

relaxed. When I read the results of your study, they hit me in the face, con-tinued this parent. I thought, yes Ive seen this! (referring to the positive

effects of nature on ADD childrens attentional functioning). In contrast,

none of the focus group participants could report any instances in which

greenoutdoor activities exacerbatedtheir childs attentiondeficit symptoms.

Hypothesis 2. The second central hypothesis in this study was that the

greener the childs everyday environment, the more manageable their atten-

tion deficit symptoms will be in general. This hypothesis was first tested byexamining the relationship between the greenness of the childs play setting

during the previous week and the severity of their attention deficit symptoms.

The mean rating of childrens overall severity of symptoms fell between

average and severe (M= 3.53, range = 1-5). Many (39%) were rated ashaving

average severity of symptoms, whereas half (50%) had symptoms that were

rated as severe or very severe. Most parents reported that their children

played inplaceswith big trees and grass (44%), or indoor placeswithout win-

dows (16%), or places where there is a lot of open grass (13%). If greennessof play environment affects attentional functioning, then children who play

in greener settings should receive lower severity of symptoms ratings.

Indeed, a regression analysis between horticulture students greenness rat-

ings of the play setting categories and parents severity of symptoms ratings

revealed a significant positive relationship,R2 = .08, F(1, 91) = 8.18,p < .01.

The greener the childs play environment during the previous week, the less

severe their symptoms.

Does this relationship hold when children were excluded from the analy-

ses if their play environments during the previous week was atypical of their

usual play environments? Yes, the relationship still held;R2= .06,F(1, 70) =

4.48,p< .05.

To further explore this relationship, Figure 2 shows the mean severity of

ADD symptoms associated with different play settings, excluding the built



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outdoors setting due to the few children in that category. The pattern ofmeans

reinforces the regression findings. In addition, the pattern of means raises the

intriguing possibility that indoor settingswithwindows may be more sup-

portive than indoor settingswithoutwindows and that there are minimal dif-

ferences between open grassy settings and settings that include trees.

This hypothesis was also examined by testing for a relationship between

various measures of residential greenness and the overall severity of symp-toms. Most childrens residential surroundings (overall greenness) were

rated as being quite green (M= 4.26, on a 5-point scale). Most children had a

large area of grass in their front yard and in their back yard (M= 2.91 and

3.27, respectively, on a 1 to 4-point scale). Children also had large amounts of

treecoverinfrontandinbackoftheirhomes(M= 2.92 and3.15, respectively,

on a 4-point scale). Based onour secondhypothesis, childrenwho live in resi-

dential areas rated as highly green should receive lower overall severity of

symptoms ratings than children who live in less green residential settings.

However, we did not find this to be the case; regression analyses indicate that

measures of overall greenness, grass cover, and tree cover in the front and

back yards were not significantly related to severity of symptoms.2

Given that three measures of nature were found to be related to attention,

why didnt we find a relationship between residential nature and severity of


Figure 2: Mean Severity of Attention Deficit Symptoms for Five Play Settings


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symptoms? One possible explanation is that the children in this sampledo not

gain much exposure to the nature surrounding their homes. It is plausible that

these childrendonot spend much time in their yards, especiallybecause there

was such a clear, significant relationship between the greenness of where

they played and the severity of their symptoms. The fact that most of the sam-

ple (75%) were boys may explain the nonsignificant relationship between

residential nature and these childrens attentional functioning (severity of

symptoms). Interviews with parents during pretesting, as well as comments

from the focus group, indicate that boys rarely play in their own yards; they

generally choose to play elsewhere.

The effects of extended contact with nature on overall severity of symp-

toms were further explored in the focus group. Parents were asked, Has any-one taken your ADD child ona purenature experience, suchas camping, hik-

ing, fishing, biking, etc. in a State park, National park, or other natural area? If

so, what happened? Anything memorable? One parents response was Pure

nature vacations are the only vacations we can take! Theme parks are a night-

mare. Two weeks camping in a pop-up camper is just bliss. We have a great

time. Hes great.

TESTING OF ALTERNATIVE EXPLANATIONS

The findings above indicate that there is a relationship between nature and

attentional functioning in children with ADD. This is consistent with

Kaplans theory that contact with nature leads to attentional restoration.

Might it be, however, that the correlations reported above were obtained in

the absence of any real relationship between nature and attentional function-

ing? In other words, does the nature-attention relationship exist merely

because both nature activities and attentional functioning are related to someother, third, factor? In searchof a potential third factor, sixalternativehypoth-

eses are considered below.

First, could it be that green activities enhance attentional functioning not

because they are green, but because they are conducted outdoors? If so, we

would expect that green outdoor activities and built outdoor activities to have

average PAAF scores that would not differ significantly. However, a pairedt

test examining differences in PAAF scores between green outdoor activities

and built outdoor activities indicates that green activities received signifi-

cantly higher average PAAF scores than built outdoor activities, t(82) = 4.38,

p< .0001 (M= 3.54 versus 3.24, respectively). Not only did built outdoor

activities receive lower PAAF scores than green outdoor activities, but a

paired ttest indicates that builtoutdoor activitiesPAAF scoresarenot signif-

icantly greater than indoor activities PAAF scores,t(82)= .29,p= .77, (M=



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3.24 and 3.24, respectively). Thus, green activities relationship to attention

cannot be explained by green activities taking place outdoors.

Second, could it be that green activities enhance attentional functioning

not because they are green but because they are conducted in a particular

social context, either alone or with one person, or with larger groups? If so,

we would expect that when social context is controlled, the physical environ-

ment in which an activity takes place would haveno effect on attention deficit

symptoms. A 2 2 (2physical settings 2 socialcontexts) repeated measures

ANOVA indicates that green outdoor activities received higherPAAF scores,

on average, than did indooractivities,F(1, 85) = 44.69,p < .0001,orbuiltout-

door activities,F(1, 72) = 13.04,p< .01. Furthermore, no interaction was

found between physical setting and social setting in either of these analyses.Thus, the social environment cannot explain the relationship between PAAF

scores and green settings.

Third, could it be that green activities enhance attentional functioning not

because they are green, but because they are physically active? If so, we

would expect that physically active green outdoor activities would receive

higherPAAF scores than passive green activities. To examine this possibility,

an independent coder coded all the activities as active or passive. For exam-

ple, reading books or magazines and creative activities were coded as pas-sive, whereas bike, skate or skateboard, explore, climb tree, or play in tree

houses were coded asactive. A paired ttest indicatesno significant difference

between PAAF scores of active and passive activities done in green settings,

t(83) = 1.13,p= .26. Thus, green activities relationship to attention cannot

be explained by green activities being either active or passive.

Fourth, could it be that green activities enhance attentional functioning

not because they are green, but because these activities are qualitatively dif-

ferent from activities done in other settings? Could it be that the activities weselected to measure PAAF for green outdoor settings happen to be uniquely

supportive of attentional functioning whereas the activities selected for the

indoor and built outdoor settings are uniquely unsupportive of attentional

functioning, thus making the differences found not due to setting but due to

the activities themselves. If so, we would expect that we would not find set-

ting differences when comparing PAAF ratings for a single set of activities

after a child does the activities in each of the three settings. The activities

matched across setting were creative activities (art, music, models, Legos,

collections, etc.), pretending (house, action figures, Power Rangers, etc.),

and organized sports. A repeated measures ANOVA comparing three differ-

ent physical settings and controlling for two social settings indicates that

attentional functioning differs systematically by physical setting,F(2, 62) =

3.06, p = .05. Moreover, paired comparisons indicated that the same



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activities, when conducted in green outdoor settings, were associated with

better attentional functioning than when they were conducted in either built

outdoor settings or indoor settings,F(1, 63) = 6.17,p< .05, andF(1, 81) =

4.14,p= .05, respectively). Thus, the differences in attentional functioning

between green activities and activities conducted in other settings seem to be

due to setting rather than activity.

Fifth, could it be that green activities enhance attentional functioning not

because they are green but because they are preferred? If this is the case, then

preferred activities should be attentionally supportive. Consistent with this

idea, attentionally supportive activities were indeed preferred; attest indi-

cated that the mean preference rating foractivities nominatedas attentionally

best for ADDchildren was significantly greater than 3.0 (a neutral preferencerating),t(62) = 29.70,p< .0001 (M= 4.70). However, preferred activities

were also nominated as attentionally worst for ADD children, t(64) = 3.03,

p


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ened attention deficit symptoms. Activities nominated as helpful in reducing

attention deficit symptoms were disproportionately likely to take place in

green outdoor settings. Conversely, activities nominated as exacerbating

symptoms were disproportionately likely to take place in non-green outdoor

settings. Parent ratings of PAAF were also systematically higher, on average,

for activities conducted in green outdoor settings than for activities con-

ducted in either built outdoor or indoor settings. Although the greenness of a

childs residential setting was unrelated to the severity of their ADD symp-

toms, the greenness of their play setting was related to symptom severity;

ADD symptoms were milder for those children with greener play settings.

Children who played in windowless indoor settings had significantly more

severe symptoms than children who played in grassy outdoor spaces with orwithout trees did.

Multiple alternative explanations for these findings were tested. The rela-

tionship between nature and attention could not be explained by confounds

between contact withnature and any of the following factors: being outdoors,

social environment, amount of physical activity, types of activity, preference

for nature, or timing of medication.

Although these findings are based on correlational data, the design of this

study provides more support for a causal interpretation than is typical forcorrelational work. First, most correlational work gives no confidence in the

temporal order of the relationship found, establishing only that A is related to

B. This study not only establishes a strong nature-attention relationship, it

also suggests a direction to that relationship. Because this study specifically

focuses on attentional functioningafteractivities, it seems more plausible

that participation in green activities causes improved attentional functioning

than that improved attentional functioning causes participation in green

activities. Remember that parents had the option of indicating that theirchilds attentional functioning was the same as usual, if indeed the child did

not improve after the activities. Second, most correlational work involves

between-subjects comparisons, in which individual differences may account

for the findings. This study establishes a strong nature-attention relationship

within subjects. We found that green activities are associated with better

attentional functioning within the same individual. Such within-individual

fluctuations in attentional functioning cannot be accounted for by

between-individual differences such as intelligence or wealth. Moreover, the

combination of between- andwithin-subjectscomparisons in this study over-

comes the limitations of a within-subjects comparison alone. For example,

parents might rate their child as functioning better attentionally after activi-

ties in green settings simply because they believe spending time in green set-

tings is good for children. This would explain the within-subjects findings



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but not thebetween-subjects findings. Thus, although definitiveevidenceof a

causal relationship awaits a true experiment, we believe the current findings

strongly merit a causal interpretation.

GENERALIZABILITY

Before we discuss the contributions and implications of these findings, a

few cautions regarding their generalizability are in order. The sample used

here, although relatively representative of the general population of ADD

children, does have some potential limitations. The children in this sample

were perceived by their parents to have relatively severe attention deficit

symptoms. Also, the families were relatively wealthy, with 63% earning anannual household income of $50,000 or more. And the majority of this sam-

ple lived in relatively green residential areas. Thus, the findings may not gen-

eralize to children with milder symptoms, who have families with lower

incomes, or who live in relatively barren residential surroundings.

In addition, the location and timing of the data collection may pose some

limitations regarding generalizability. The data were collected from a limited

geographic region, the midwestern United States. Thus, the question arises,

do these findings apply to children living in regions without green trees andgrass? For example, children in desert settings may not receive the same ben-

efits from contact with nearby natural outdoor settings. Furthermore, this

study was conducted within a short period of time during a single season,

autumn. Is the nature-attention relationship still as strong during the summer

months, when children have fewer attentional demands (i.e., no school-

work)? Is the nature-attention relationship as strong during the winter

months, when there is very little green vegetation available?

CONTRIBUTIONS

This work contributes to the research on nature and attention in three

ways. The work here extends Attention Restoration Theory, expands the lit-

erature concerning children andnature, andprovides a potentialnew method-

ology for studying directed attention in children.

This study extends Attention Restoration Theory toa new population, pro-

viding evidence that the theory may apply to children. Whereas Attention

Restoration Theory suggests that nature supports directed attention function-

ing in all humans, previous research has only provided evidence that the the-

ory applies to adults (Canin, 1991; Cimprich, 1990; Hartig et al., 1991; Kuo,

in press; Lohr et al., 1996; Miles et al., 1998; Tennessen & Cimprich, 1995).

This study is the first to indicate that the theory applies to at least a subpopu-



20/24

lation of children, children with ADD. Thus, there is now evidence that

Attention Restoration Theory applies to both adults with normal attentional

functioning and children whose attentional functioning is compromised.

Together, these findings provide some indication that the nature-attention

relationship may apply to all children.

This study also extends the literature on the benefits of nature for children.

The previous literature has provided some evidence that green spaces foster

play andofparticular importancecreative play (Kirkby, 1989;Moore, 1989;

Taylor et al., 1998). In addition, previous investigators have suggested that

contact with nature supports childrens general well-being by providing chil-

dren with privacyandmentalandsensory stimulation (Heseltine, 1987; Jansson,

1984; Miller, 1972; Nabhan & Trimble, 1994; Senda, 1992; Striniste & Moore,1989). To date, however, no studies have examined the effects of contact with

nature on childrens attentional functioning. Trancik and Evans (1995) did

speculate that, for preschoolers, the stress of the new school environment

might cause attentional fatigue and that, therefore, preschoolers might bene-

fit from opportunities to play in green settings. The findings here suggest that

Trancik and Evanss ideas are worth testing.

Finally, this study provides a potential new methodology for studying

directed attention in children. The consistent and statistically significant dif-ferences between different activities found here suggest that parents are able

to systematically assess the aftereffects of activities on their childrens

attentional functioning and can estimate the magnitude of these effects on a

Likert-type scale. Furthermore, it appears that most parents are able to nomi-

nate activities that have especially positive and negative effects on their

childs attention. Future research should assess the reliability and concurrent

validity of these measures.

IMPLICATIONS FOR PRACTICE AND FUTURE RESEARCH

The findings here have a number of implications for practice and future

research. For childrenwithADDand their parents, these findings havea clear

and inexpensive implication: Children with ADD can support their

attentional functioning and minimize their symptoms simply by spending

time in green settings. More specifically, children with ADD might use these

findings in the following ways. First, before engaging in attentionally

demanding tasks such as schoolwork and homework, ADD children might

maximize their attentional capacity by spending time in green settings. Sec-

ond, ADD children might reduce the overall severity of their symptoms by

spending time in green settings on a daily basis. According to parents in the

focus group, children with ADD who engage in green activities function



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better both during the activity and for some time afterward. It is worth noting

that children with ADD can follow these recommendations at little or no

financial cost by using public and private green areas.

The findings of this study have implications for the design of childrens

environments such as school yards. Given that maximal attentional function-

ing is necessary for optimal academic performance, one implication of these

findings is that green schoolyards could play an important role in childrens

academic pursuits. For example, recess may be more than just a time for

releasing physical energy but also an important time for restoring attention.

Children with ADD, and possibly all children, may perform better through-

out the school day if given breaks in a green environment. In addition, per-

haps something as simple as a view out the classroom window onto a greenspace may be providing children with much needed rest of their directed

attention.

The findings of this study also have a number of implications for future

research. Future research might replicate these findings both in similar set-

tings (childrens afterschool and weekend play environments), with other

populations (e.g., ADD children in the southwest United States, non-ADD

children), and in other settings. For example, do children who attend schools

with particularly green school yards function better attentionally throughoutthe day than children who attend less green schools? Does the physical set-

ting of summer campaffectADDchildrens attention deficit symptoms? Per-

haps, summer camps in natural settings (e.g., camping in a state park) are

more beneficial for children with ADD than indoor summer camps (e.g.,

indoor sports camps or arts camps). Furthermore, future research might

explore which specific elements of green settings are crucial in supporting

attentional functioning.

Future research might also explore the temporal characteristics of thenature-attention relationship. In this study, we examined functioning imme-

diately after participation in green activities but did not measure the duration

of the activities or the duration of the effects. Is it necessary to spend some

minimum amount of time in nature-related activities to experience the restor-

ative benefits of nature? For children with ADD, how does a 10-minute walk

in the park compare to a 30-minute walk in the park in terms of restoring

attentional functioning? Kuo (in press) has proposed that future research

should determine the shape of thedose response curvefor nature and atten-

tion. For example, perhaps attentional functioning increases with increasing

exposure to nature only up to a point, after which the benefits level out and

additional exposure to natureproduces littleadditional benefit.Another issue

that deserves investigation concerns the duration of the effects. How long do



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they last? Do the effects degrade in a linear fashion or do they degrade

suddenly?

This study has shown that nature may support attentional functioning in

children with ADD. These finding have tremendous implications for a large

number of children (more than 2 million in the United States alone) strug-

gling day-in and day-out with attention deficit symptoms. These childrenand

their families could potentially benefit from something as simple as spending

time in green areas. In addition, these findings hold potential value for chil-

dren who do not have ADD. Optimal levels of attentional functioning are

essential forallchildren so that they maximize learning and achievement in

school. Thus, all childrens attentional functioning may benefit from some-

thing as inexpensive and direct as incorporating vegetation into places wherechildren live, learn, and play.

NOTES

1. TheacronymADDwill be used throughout this article because this research theoretically

hinges on childrens attention deficits. However, the information also applies to ADHD, asADHD is a broader diagnostic term under which a child canbe diagnosedaspredominantly inat-

tentive (attention deficit), or inattentive andhyperactive/impulsive (AmericanPsychiatricAsso-

ciation, 1994).

2. It is striking that in spite of a smallnand thus low power for analysis, girls severity of

symptoms were significantly related to several measures of residential greenness.

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